The Clinical Documentation Specialist (CDS) facilitates improvement in the overall quality, completeness and accuracy of medical record coding and documentation. The (CDS) reviews inpatient medical records concurrently, while the patient is still in-house, facilitating appropriate physician documentation for any clinical conditions or procedures to support appropriate MS-DRG assignment,severity of illness, expected risk of mortality, core measures, and complexity of care of the patient. Obtains and promotes appropriate clinical documentation through interaction with the HIM department, physicians, nursing staff and other clinical providers of care. This includes review of all new admissions to the acute care facility, as well as re-reviews until the patient is discharged. The CDS communicates with HIM, clinicians and physicians to ensure timely and accurate documentation and provides training and education as required.
BASIC KNOWLEDGE AND ABILITIES:
Education / License / Certification:

• Licensed as a Registered Nurse in the state of Tennessee or compact state in good standing

Experience / Skills:

• Five (5) years acute hospital nursing experience (e.g. medical-surgical, ICU, case management, etc.)
• Must possess a comprehensive knowledge of medical terminology, disease processes and clinical competency
• Sufficient knowledge of clinical documentation requirements, DRG assignment, ICD-10-CM diagnosis and procedure coding and clinical conditions or procedures
• ICU/Critical Care experience highly desired
• Previous experience working in a clinical documentation improvement department or as a consultant strongly encouraged
• Minimum of one (1) year auditing experience strongly encouraged
• Experience in Utilization Management/Case Management, Critical Care, patient outcomes/quality management and/or inpatient coding preferred
• Prior experience educating physicians/providers preferred
• Attention to detail and concentration
• Ability to work in fast-paced, ever-changing environment